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Periodic Limb Movement

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3041. Compartment Syndromes

be relatively minor. Intense exercise can also cause acute compartment syndrome. Acute compartment syndrome requires prompt diagnosis and urgent treatment. Chronic compartment syndrome is usually caused by exercise and presents with recurrent pain and disability, which subside when the cause (usually running) is stopped but return when the activity is resumed. Sites affected Compartment syndrome can occur wherever a compartment is present. Therefore, although the upper and lower limbs are most commonly (...) affected, other sites may be affected, particularly the abdomen and gluteal regions: Forearm compartments and structures at risk: Ventral compartment: median and ulnar nerves; radial and ulnar arteries. Dorsal compartment: posterior interosseous nerve; no major vessels. Lower limb and structures at risk: Anterior tibial compartment: deep peroneal nerve, anterior tibial artery. Superficial posterior compartment: no major nerves or vessels. Deep posterior compartment: posterior tibial nerves and vessels

2008 Mentor

3042. Acromioclavicular Joint Problems

and/or localised AC joint pain. May be simply an ache in the deltoid area. Often worse at night. Local tenderness with exacerbation on passive and active shoulder movements. Cross-adduction (ie reach over front of opposite shoulder) often worsens pain; further passive cross-adduction by the examiner may aggravate this. It is important to differentiate OA from instability. Reduced range of movement is rare unless there is a prolonged period of arthritis. Differential diagnosis Clavicular fracture. Shoulder (...) on research evidence, UK and European Guidelines. You may find the article more useful, or one of our other . In this article In This Article Acromioclavicular Joint Problems In this article Synonyms: collar bone/clavicle disorders Description The acromioclavicular (AC) joint is the articulation between the acromion process of the scapula and the lateral end of the clavicle. It is one of the important functional joints that allows a full range of movement at the glenohumeral joint. A joint capsule

2008 Mentor

3043. Whiplash and Cervical Spine Injury

injury occur as the result of rear-end vehicle collisions at speeds of less than 14 miles per hour. Patients present with neck pain and stiffness, occipital headache, thoracic back pain and/or lumbar back pain and upper-limb pain and paraesthesia. [ ] There are two types of injury: Typical cervical hyperextension injuries occur in drivers/passengers of a stationary or slow-moving vehicle that is struck from behind. The person's body is thrown forward but the head lags, resulting in hyperextension (...) of the neck. When the head and neck have reached maximum extension, the neck then snaps into flexion. A rapid deceleration injury throws the head forwards and flexes the cervical spine. The chin limits forward flexion but the forward movement may be sufficient to cause longitudinal distraction and neurological damage. Hyperextension may occur in the subsequent recoil. Whiplash-associated disorders (WAD) can be classified by the severity of signs and symptoms: [ ] Grade 0: no complaints or physical signs

2008 Mentor

3044. Werdnig-Hoffmann Disease

than distal, with lower limbs generally weaker than upper limbs. Deep tendon reflexes are absent or diminished but sensitivity is preserved. In the most severe forms decreased intrauterine movements suggest prenatal onset of the disease and present with severe weakness and joint contractures at birth (this has been labeled SMN0). Some of these children may also show congenital bone fractures and extremely thin ribs. The spared diaphragm, combined with weakened intercostal muscles, results (...) . Within SMA1 at least three clinical subgroups can be defined according to the severity of clinical signs: Severe weakness since birth/neonatal period - head control is never achieved. Onset of weakness after the neonatal period but generally within two months - head control is never achieved. Onset of weakness after the neonatal period but head control is achieved. Some of these children may be able to sit with support. Differential diagnosis Includes: Amyotrophic lateral sclerosis. Congenital

2008 Mentor

3045. Hyaluronates and Viscosupplementation

. Reduced function and participation restriction. Signs Reduced range of joint movement. Pain on movement of the joint or at extremes of joint movement. Joint swelling/synovitis (warmth, effusion, synovial thickening). Periarticular tenderness. Crepitus. Absence of systemic features such as fever or rash. Bony swelling and deformity due to osteophytes - in the fingers this presents as swelling at the distal interphalangeal joints (Heberden's nodes) or swelling at the proximal interphalangeal joints (...) on their joints and help to improve pain. The use of local heat or cold (thermotherapy) should be considered as an adjunct to core treatments. Aids and devices: Advice on appropriate footwear (including shock-absorbing properties) as part of core treatments for people with lower-limb OA. Biomechanical joint pain or instability: should be considered for assessment for bracing/joint supports/insoles as an adjunct to their core treatments. Assistive devices (eg, walking sticks and tap turners) should

2008 Mentor

3046. Huntington's Disease

with HD it has been reported to be as common as 69%. [ ] HD then leads to progressive chorea, rigidity and dementia. It is frequently associated with seizures. Chorea is initially mild but may be severe and cause uncontrollable limb movements. As the disease progresses, chorea is gradually replaced by dystonia and Parkinsonian features. Dysarthria, dysphagia and abnormal eye movements are common. There may also be other movement disorders - eg, tics and myoclonus. HD patients can develop a wide array (...) variable. JHD (6% of all cases of HD) is defined as an age of onset of younger than 20 years. It causes Parkinsonian features, dystonia, pyramidal tract signs, dementia and epilepsy. Chorea is often mild and may be absent. Differential diagnosis Neuroacanthocytosis: a group of genetic conditions that are characterised by movement disorders and acanthocytosis (abnormally-shaped red blood cells). and other causes of . Other causes of . Investigations MRI and CT scans in moderate-to-severe HD show a loss

2008 Mentor

3047. Hand Arm Vibration Syndrome

Guidelines. You may find the article more useful, or one of our other . In this article In This Article Hand-arm Vibration Syndrome In this article Synonyms: HAVS, vibration white finger, VWF Prolonged exposure to hand-arm vibration may cause a potentially disabling chronic disorder of the upper limbs, which is called the hand-arm vibration syndrome (HAVS). As well as vascular and neurological injury, HAVS may also involve damage to bones, joints, muscles and tendons in the upper limbs. There may also (...) (little finger) in each hand at two frequencies. The thermal aesthesiometry test, which assesses the thermal receptors' threshold. Readings are again taken from the median nerve and the ulnar nerve. The Purdue Pegboard test, which is a measure of dexterity and detects loss of fine movement to both hands. The grip force measurement test, which measures the grip strength of both hands. This test is not scored but is a useful indication of vibration damage to muscles of the hand and forearm. In addition

2008 Mentor

3048. Enteropathic Arthropathies

, less frequently, with other rheumatic disease such as rheumatoid arthritis, Sjögren's syndrome, Takayasu's arteritis and fibromyalgia. The joint involvement observed in IBD is usually classified into axial (including sacroiliitis with or without spondylitis) and peripheral. Axial involvement is found to be present in 2-16% of patients with IBD. Peripheral joint involvement has been reported in a wide range (0.4-34.6%) of patients with IBD. It predominantly affects the joints of the lower limbs (...) before, simultaneously or after the diagnosis of IBD. Symptoms Axial arthritis (spondylitis and sacroiliitis) associated with IBD : The condition may precede any GI symptoms and be active despite good control of bowel disease. There is a gradual onset of low back pain radiating down the back of the legs. Symptoms tend to be worse in the morning. Prolonged sitting or standing can bring the symptoms on. Moderate movement tends to improve the symptoms. The arthritis tends to be chronic and long-standing

2008 Mentor

3049. Epilepsy in Adults Full Text available with Trip Pro

, which lower the seizure threshold. It is common for seizure frequency to vary throughout the menstrual cycle. In ovulatory cycles, peaks occur around the time of ovulation and in the few days before menstruation. In anovulatory cycles, there is an increase in seizures during the second half of the menstrual cycle. [ ] Possible seizure-related symptoms include: Sudden falls. Involuntary jerky movements of limbs whilst awake. Blank spells. Unexplained incontinence of urine with loss of awareness (...) , or in sleep. Odd events occurring in sleep - eg, fall from bed, jerky movements, automatisms. Episodes of confused behaviour with impaired awareness. Possible simple focal seizures. Epigastric fullness sensation. Déjà vu. Premonition. Fear. Elation, depression. Depersonalisation, derealisation. Inability to understand or express language (written or spoken). Loss of memory, disorientation. Olfactory, gustatory, visual, auditory hallucinations. Focal motor or somatosensory deficit, or positive symptoms

2008 Mentor

3050. Gait Abnormalities in Children

as the leg swings forwards Typically seen with a leg length discrepancy, with a stiff/restricted joint movement as in JIA, or with unilateral spasticity as in hemiplegic . Spastic gait Stiff, foot-dragging with foot inversion. This is often seen in upper motor neurone neurological disease (eg, diplegic or quadriplegic cerebral palsy, ). Ataxic gait Instability with an alternating narrow-to-wide base. Seen in ataxic cerebral palsy affecting the cerebellum, in , and in . Trendelenberg's gait Results from (...) with absent heel contact Habitual toe walking is common in children and associates with normal tone, range of movement around the feet and normal walking on request. However, persistent toe walking is observed in spastic upper motor neurone neurological disease (eg, cerebral palsy). It can (rarely) be a presentation of mild lysosomal storage disorder. Stepping gait The entire leg is lifted at the hip to assist with ground clearance. Occurs with weak ankle dorsiflexors, compensated by increased knee

2008 Mentor

3051. Flying with Medical Conditions

. Trauma or surgery of the lower limbs. Family history of DVT. Age >40 years. The oral contraceptive pill. The risk of flight-related VTE is also increased in both shorter and taller individuals and in the overweight and is associated with location in a window seat [ ] . DVT prophylaxis It is wise for anyone undertaking a long-haul flight to take sensible precautions, such as to: Remain adequately hydrated. Exercise the calves. Spend periods out of their seat. Avoid excess alcohol. Avoid tight-fitting (...) below. Physiology during flight [ ] Modern aircraft are not pressurised to sea level equivalent. Cabin altitude equivalent is usually between 5,000 and 8,000 feet which means that there is a reduction in barometric pressure and a reduction in the partial pressure of alveolar oxygen (P a O 2 ). Sometimes during flight, although not usually for long periods, oxygen saturation levels can fall to around 90%. A healthy individual can usually tolerate this with no problems but it may not be the same

2008 Mentor

3052. Night Terrors and Parasomnias

, the symptoms are frequently amenable to medication. Restless legs syndrome and periodic limb movement disorder These two conditions may co-exist. RLS tends to cause insomnia due to a constant, involuntary irritation of the legs causing their movement, on retiring to bed. Periodic limb movement disorder (PLMD) causes temporally-periodic, sleep-disturbing limb movements that rarely completely wake the sufferer but may cause them to feel excessively sleepy during the next day, due to disturbance of the sleep (...) of parasomnia. Clin Neurol Neurosurg. 2010 Jan112(1):72-5. Epub 2009 Sep 17. ; REM sleep behavior disorder: Updated review of the core features, the REM sleep behavior disorder-neurodegenerative disease association, evolving concepts, controversies, and future directions. Ann N Y Acad Sci. 2010 Jan1184:15-54. doi: 10.1111/j.1749-6632.2009.05115.x. ; Epidemiology of restless legs syndrome: The current status. Sleep Med Rev. 2006 Jun ; Restless legs syndrome and periodic limb movement disorder in the elderly

2008 Mentor

3053. Newborn Screening

. But the following specific aspects of the examination are part of the screening programme and subject to pathway standards. This is used to screen for: - by ophthalmoscope examination. - by examination of the cardiovascular system. - by palpation of the scrotum and inguinal canals. - by the Barlow and Ortolani tests and examination of the lower limbs for asymmetry or limited abduction. Newborn hearing screening Parents are offered a hearing screen for their baby within 4-5 weeks of birth. The screen is usually (...) or heterozygous compound mutation in the gene encoding glutaryl-CoA dehydrogenase on chromosome 19p13. Gliosis and neuronal loss in the basal ganglia lead to a progressive neurodegenerative and movement disorder that usually begins in the first year. Untreated patients characteristically develop dystonia during infancy, resulting in a high morbidity and mortality. Initiation of treatment after the onset of symptoms is generally not effective in preventing permanent damage and so early diagnosis is essential

2008 Mentor

3054. Parkinsonism and Parkinson's Disease

is usually apparent in one limb or the limbs on one side for months or even years before becoming generalised. Rigidity presents as an increase in resistance to passive movement that can produce a characteristic flexed posture in many patients. It may be increased by asking the patient to perform an action in the opposite limb - contralateral synkinesis. Bradykinesia presents as a slowness of voluntary movement and reduced automatic movements. It is particularly noticeable in a reduced arm swing whilst (...) as a unilateral or bilateral, low-frequency intention tremor. It may be caused by stroke, brainstem tumour, or multiple sclerosis. Pyschogenic tremor - the tremor is variable, increases under direct observation, decreases with distraction and changes with voluntary movement of the contralateral limb. The 'atypical Parkinsonism syndromes' are a group which look like Parkinson's disease but are much more severe. Median survival is only seven years compared with the normal lifespan in Parkinson's disease

2008 Mentor

3055. Pain Control in Terminal Care

Bisphosphonates Bone pain Ketamine (specialist use only) Refractory pain Neuropathic pain Ischaemic limb pain Where pain is continuous, analgesia needs to be prescribed on a regular not 'as-required' basis. Explain that pain is easier to prevent than it is to relieve and drugs should be prescribed on a prophylactic basis with no other consideration than maintaining quality of life. Prescribe also for breakthrough or incident/episodic pain that occurs with everyday activities such as walking. Explain (...) relaxation, hypnosis. Capsaicin cream. Local nerve blocks and epidurals. Acupuncture. Transcutaneous electrical nerve stimulation (TENS). Episodic/incident pain Bony pain due to metastases in the spine, pelvis or femora, exacerbated by walking or weight-bearing can be particularly problematic. Opioids plus NSAIDs are the mainstay; however, doses sufficient to control pain on movement cause sedation when the patient is at rest. Advise prn doses of immediate-release opioid in anticipation of movement

2008 Mentor

3056. Osteoarthritis

. Reduced function and participation restriction. Signs Reduced range of joint movement. Pain on movement of the joint or at extremes of joint movement. Joint swelling/synovitis (warmth, effusion, synovial thickening). Periarticular tenderness. Crepitus. Absence of systemic features such as fever or rash. Bony swelling and deformity due to osteophytes - in the fingers this presents as swelling at the distal interphalangeal joints (Heberden's nodes) or swelling at the proximal interphalangeal joints (...) on their joints and help to improve pain. The use of local heat or cold (thermotherapy) should be considered as an adjunct to core treatments. Aids and devices: Advice on appropriate footwear (including shock-absorbing properties) as part of core treatments for people with lower-limb OA. Biomechanical joint pain or instability: should be considered for assessment for bracing/joint supports/insoles as an adjunct to their core treatments. Assistive devices (eg, walking sticks and tap turners) should

2008 Mentor

3057. Opiate Poisoning

Morphine Opium Oxycodone Pentazocine Tramadol They may come alone or in combination when the situation becomes more complex. Epidemiology [ ] It is difficult to get reliable incidence figures. The elderly are more liable to poisoning from opiates and more likely to be taking them, especially drugs like co-codamol for arthritis. The Office for National Statistics (ONS) published figures for deaths related to drug poisoning in England and Wales for the year 2012. During this period there were 579 deaths (...) an accidental overdose of an opiate. [ ] Differential diagnosis There may be no clear indication of what the patient has taken. He or she may be a known drug abuser or there may be needle track marks on the limbs. Beware of multiple drug ingestion (eg, antidepressants, alcohol or benzodiazepines), especially in drug abusers or with suicidal intent. [ ] Other conditions which may need to be considered include: . . . Hyperosmolar hyperglycaemic nonketotic coma. . . . . . . . Investigations It is possible

2008 Mentor

3058. Osteomyelitis

and is a high risk factor for adverse outcome. Early diagnosis is crucial to ensure correct management [ ] . Peripheral arterial disease. Chronic joint disease. Alcoholism. Intravenous drug abuse. Chronic steroid use. Immunosuppression. Tuberculosis. HIV and AIDS. Sickle cell disease. Presence of catheter-related bloodstream infection. Presentation Haematogenous osteomyelitis Long bone Classic presentation : The acutely febrile and bacteraemic patient presents with a markedly painful, immobile limb (...) . There may be swelling and extreme tenderness over the affected area with associated erythema and warmth. The pain is exacerbated by movement and there may be sympathetic effusion of neighbouring joints. In neonates and infants, there may be an associated septic arthritis. Other presentations : Occasionally, the patient may present with mild symptoms, perhaps a history of blunt trauma to the area which may or may not be remembered (eg, a bump against a hard surface) 24-48 hours previously and mild

2008 Mentor

3059. Paediatric Examination

whether the child has normal development in motor functions, speech and language and social interaction. Note whether there are any specific concerns stated by the parent/s. Always examine the anterior fontanelle by palpation in babies and infants. Note any pulsation and if it is normal. The fontanelle should close by the middle of the second year. It should be full or flat. Note if the child can hear, see, move the eyes and head well in all directions, move all limbs and whether this movement (...) is normal and full. Note whether contour and position of each limb are normal with good power. Handle the child and note the tone of movement of the limb and whether there is any limitation to this. Note if the joints are unduly lax and hyperextendable. Watch the child's face while you move the limbs. [ ] Although rarely useful, you may be able to elicit reflexes with the percussing finger instead of a hammer. Examination at different ages Examination will be outlined in different age groups

2008 Mentor

3060. Obstructive Sleep Apnoea (OSA)

diagnosis Fragmented sleep (quality of sleep). Sleep deprivation (quantity of sleep). Shift work. . . . /periodic limb movement disorder. Drugs: Sedatives. Stimulants (caffeine, theophyllines, amfetamines). Beta-blockers. Selective serotonin reuptake inhibitors (SSRIs). Idiopathic hypersomnolence. Excess alcohol. Neurological conditions: Dystrophica myotonica. . . . Diagnosis OSAS is defined by five or more respiratory events (apnoeas, hypopnoeas or arousals) per hour, in association with symptoms (...) at night and excessive sleepiness during the day. Complete apnoea is defined as a ten-second pause in breathing activity. Partial apnoea, also known as hypopnoea, is characterised by a ten-second period in which ventilation is reduced by at least 50%. Research is focusing on the concept of sleep fragmentation (the poor-quality sleep produced by repeated episodes of apnoea or hypopnoea) and objective measurements of upper airways obstruction. Epidemiology OSAS is a worldwide phenomenon. The prevalence

2008 Mentor

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